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The Integrated Client Care Project: Intent and Insights

Presentation at the Ontario Wound Care Interest Group’s 4th Annual Symposium April 19, 2013

ROSEMARY HANNAM, MBA Senior Research Associate

Collaborative for Health Sector Strategy Rotman School of Management

105 St. George Street Toronto ON M5S 3E6 phone: 416 946 3492

[email protected]

1

The experiences of the Integrated Client Care Project (ICCP)

between 2008 and 2012 offer valuable insights as OntWIG

moves forward.

A: Intent – A history of ICCP, key concepts and milestones:

• Value-based theory and the original policy intent of the project

• Governance & implementation structure

• Translation into the six “puzzle pieces”

• Rationale behind the choice of wound care

• Support provided

• Progress and evolution

B: Insights, Challenges, and Barriers

• Integrated System of Wound Care

• Evidence based practice

• Patient-centred

• Value-based

C: Concluding thoughts

1

Outline

2

In December 2008, Cabinet launched “Strengthening Home

Care Services in Ontario”, officially introducing

Porter/Teisberg ideas to home and community care.

2

Outline Value-Based theory and the original policy intent

3

Value

Quality of the

person’s experience

• For the full cycle of care

• Quality includes clinical outcomes and the person’s experience

Dollars spent

4

Achieving Value Organize into Integrated Practice

Units (IPUs) around the patient’s /

client’s condition

Measure

outcomes and

cost for every

patient / client

Reward

providers

based on

results

Create Enabling

Information Technology

Realize value

through learning

and scale

economies;

Grow by

expanding

excellent IPUs

Move to Bundled

Prices for Care Cycles

Organization

Measure

Positive

Competition

Bundling

Size

Information

5

ICCP Governance and Oversight Membership in the steering committee & teams included representatives

from CCACs, LHINs, primary care, acute care, relevant associations &

HQO.

Integrated Client Care Project

Steering Committee

MOH Chair, External Vice Chair

Resource

Tables

Project Management - OACCAC

Design Model & Site

Selection Work Group

Evaluation Work Group

Education & Change

Management Work

Group Implementation Oversight:

Strategic Oversight Group (one, for all sites)

Local Oversight Group (four, one at each site)

Improvement Teams (four, one at each site)

6

From Principles to Practice

Organization

Measure

Positive

Competition

Bundling

Size

Information

Aligned with

reimbursement

that is based

on outcomes

and rewards

innovation

Informed by

Clinical / Leading

Practice

Delivered by

Integrated

Clinical

Service Teams

Enhanced with

Specialized

Case

Management

Facilitated by

Coordinated

Assessment

Strengthened

by

System-Wide

Navigation and

Integration


7

Delivered by

Integrated

Clinical

Service Teams

ICCP: Achieving Value for the Client in Home Care


Enhanced

with

Specialized Case

Management

Facilitated

by

Coordinated

Assessment

Strengthened

by System-Wide

Navigation and

Integration

Informed

by Clinical /

Leading Practice

Aligned with

reimbursement

that is based on

outcomes and

rewards innovation

8

Rationale for Wound Care


Wound care, including hips and knees, met ICCP’s #1 criterion:

Significant portion of system resources, in home care and across

the system.

Wound care also met ICCP’s “value-based” criteria:

• There is significant potential to improve client outcomes.

• There is significant potential for efficiencies and cost savings.

• The grouping requires interventions of multiple care providers.

• The grouping requires specialized interventions.

• There are opportunities to leverage ongoing activities in this grouping.

• There are opportunities to create linkages to acute, primary and community care.

• The grouping has established, measurable client outcomes.

• It would be possible to set up a method for measuring client outcomes.

• It would be possible to create and retrieve information from an integrated client record.

• There is costing data available for the grouping.

9

Delivered by

Integrated

Clinical

Service Teams

ICCP: Outcome Based Reimbursement


Enhanced

with

Specialized Case

Management

Facilitated

by

Coordinated

Assessment

Strengthened

by System-Wide

Navigation and

Integration

Informed

by Clinical /

Leading Practice

Aligned with

reimbursement

that is based on

outcomes and

rewards

innovation

10

ICCP

Diabetic Foot Ulcers & Venous Leg Ulcers

1

2

3

3

4 1

2

3

4

Erie St. Clair CCAC

and Saint Elizabeth

Health Care

Central West CCAC

and Saint Elizabeth

Health Care

Northeast CCAC

and Bayshore

Home Health

Champlain CCAC

and Carefor Health

and Community

Services

11

Support


Each site was provided with: • Four education sessions provided jointly by the three partners,

including travel and accommodation

• On-site training and coaching from the Centre for Health

Quality Improvement (later HQO)

• Institute for Healthcare Improvement (IHI) training for one staff

member per site

• Contract management support

• Communications support

12

Progress and Evolution

Overall, progress significant given barriers and challenges.

• Training and coaching completed in all four sites

• Evaluation team in place since June 2010

• 2 bundled payment trials performed, one in Champlain and one in

Central West, providing insights into how to design a workable

outcome-based payment system.

• Education of stakeholders (providers, CCACs, primary care, LHINs

etc. ) through a series of presentations and consultations

• Development of CHRIS enhancements necessary for client

identification and outcome measurement

13

Progress and Evolution

ICCP wrapped up in June of 2012 and deliverables

migrated to the relevant organizations:

• Outcome Based Pathways and Reimbursement now with

the Ministry of Health and the OACCAC, forming the

homecare/community portion of the Quality Based

Procedures system.

• Integrated teams, specialized case management, system

navigation and coordinated assessment with the

OACCAC as part of the “Quality and Value in Home Care”

initiative.

14

Connecting the ICCP and OntWIG Frameworks


Delivered by

Integrated

Clinical

Service

Teams

Enhanced

with

Specialized

Case

Management

Facilitated

by

Coordinated

Assessment

Strengthened

by System-

Wide

Navigation

and

Integration

Informed

by Clinical /

Leading

Practice

Aligned with

reimbursement

that is based on

outcomes and

rewards

innovation

15

Connecting the ICCP and OntWIG Frameworks

Integrated

Clinical

Service

Teams

Specialized

Case

Management

Coordinated

Assessment

System

Navigation

and

Integration

Clinical/Leading

Practice

Outcome-

based

reimburse-

ment

Integrated

Evidence-based

Patient-Centred - all

Value-based

16

Integrated

• A compelling concept with universal agreement.

• Cross sector integration always a long term goal of ICCP, but

success requires structural/budgetary alignment and change.

• Incentives designed to enable alignment across sectors – outcomes,

pathways, rewards should be consistent. E.g. “Avoidable

readmission”

• Importance of stakeholder management/engagement – building trust,

communicating with those directly and indirectly involved.

16

Insights, Challenges and Barriers

17

Evidence-based practice • Ensuring the system of wound care supported evidence-based

practice was a primary goal of ICCP. This was the reason behind

changing the framing from services to outcomes.

• Much time spent understanding structural, organizational and system

factors that allow/prevent evidence based practice to flourish.

• Contracts, service structure

• Availability of resources, supplies, equipment, expertise – e.g.

devices

• Outcome-based pathways were developed and operationalized in

CHRIS to support evidence-based practice.

17


18

Patient-centred

• ICCP aimed to align system incentives, including payment, with client

goals.

• ICCP raised awareness and reinforced the language.

• Always valuable to bring any discussion back to the patient’s

perspective, and frame any proposed change/idea from their point of

view. Tell their stories.

• Using Picker Principles a great idea, since hospitals and others use

the same ones.

18


19

Value-based

• The term “value” was new in 2008 – now we hear it all the time, and

for good reason.

• Framing the case for change in terms of value was effective for ICCP,

and continues to be a compelling approach. Always be ready to give

examples/cases.

• The more inclusive in terms of services, the greater the potential for

innovation and value creation. Equipment? Specialty services?

Physician services? Drugs?

• The processes for measuring and reimbursing outcomes are just as

important as the outcomes and associated price.

• Importance of shared information systems to reduce administrative

burden can’t be emphasized enough.

• The Ministry of Health embraced and continues to support the ideas

of value-based care.

19


20

The experiences of the Integrated Client Care Project (ICCP)

between 2008 and 2012 offer valuable insights as OntWIG

moves forward.

• Communication, communication, communication

• Despite challenges, cross-sector efforts have great potential and are

worth pursuing.

• However, it’s a balance between making compromises and reinforcing

the “old ways”.

• There are many agendas; recognize & manage conflicts of interest.

• Ensure redundancy in key roles so departures won’t affect progress.

• Prioritize and resource accordingly; who/whatever has the most

resources will define what gets done.

• Information management and data strategy essential

• Communication, communication, communication

20

Concluding thoughts

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